Fueling Life: A Clinical Look at Macronutrient Deficiency Disorders
A course dedicated to educating others about the causes, consequences, and prevention of macronutrient deficiencies.
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What Are Macronutrient Deficines?
You are what you eat — and what you don’t eat can hurt you.Macronutrient deficiencies occur when the body doesn’t receive enough of the three key nutrients it needs in large amounts: carbohydrates, proteins, and fats. These nutrients are essential for energy, growth, repair, and survival. A lack of any one macronutrient can lead to serious health consequences, especially in vulnerable populations like children. This course will explore the causes, symptoms, and real-life impacts of macronutrient deficiencies — including severe conditions like kwashiorkor, marasmus, anorexia and bulimia
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Module Breakdown:
Marasmus
Kwashiorkor
Bulimia
Anorexia
Works Cited
Quiz
01
Kwashiorkor
01
What is it?
Kwashiorkor is a form of severe malnutrition that happens when the body doesn't get enough protein, even if it gets enough calories. It mostly affects young children, especially in areas where food source is scarce. Common signs include a swollen belly, thin muscles, irritability, and changes in skin and hair. Without proper treatment, kwashiorkor can be life-threatening. It’s important to understand this condition so we can recognize and help prevent it1,2.
Signs
Swelling (Edema) & Enlarged Abdomen: Swelling in feet, legs, and sometimes the face. The belly may appear bloated or puffy because of fluid buildup and weak abdominal muscles3. Changes in Hair and Skin: Hair may become thin, brittle, and change color (often reddish or yellowish). Skin may develop dark patches, cracks, or become flaky4. Irritability and Behavioral Changes: Children may seem fussy, anxious, or withdrawn5. Slow Growth and Weight Gain: Children often stop growing properly and may not gain weight as expected for their age6.
Symptoms
Fatigue and Weakness: Children may seem constantly tired, have little energy, and struggle with physical activity2.Loss of Muscle Mass: Muscle wasting may occur, especially in the arms and legs, although the swelling can hide this3. Poor Appetite: Unlike other forms of malnutrition, children with kwashiorkor may not feel hungry7. Infections: A weakened immune system increases the risk of frequent or severe infections8. Slow Wound Healing: Cuts and sores may heal slowly due to poor nutrition and reduced protein levels9.
ETIOLOGY (the why?)
Development
Info
100% Severe Protein Deficiency
Brain structue & Function
Info
Info
Enviornment
Info
ETIOLOGY (the why?)
Development
Info
100% Severe Protein Deficiency
Brain structue & Function
Info
Info
Enviornment
Info
Who Does Kwashiorkor Affect?
Poverty
1.7 Million
Children
Young children between 1-5 years old
Sub-Saharan Africa & South Asia
Globally/Anually
The highest number of cases are found in low-income regions, particularly in Sub-Saharan Africa, South Asia, and parts of Central America, where access to protein-rich foods is limited due to poverty, drought, or conflict15,16,22
Over 1.7 million children suffer from severe acute malnutrition with edema—a hallmark of Kwashiorkor—every year. Without treatment, it can lead to long-term developmental issues or death21.
Especially children during or after the weaning period. Their bodies need more protein for growth, making them especially vulnerable to deficiency.1,10,20
PATHOGENESIS (the how?)
Oxidative Stress & Inflammation
Fatty Liver Development
Gut Microbiome Disruption
Metabolic Failure
Next
Treatment
Treating kwashiorkor requires a careful, staged approach to correct nutritional deficiencies, manage complications, and support long-term recovery. Sudden or aggressive feeding can be dangerous, so treatment must be gradual and closely monitored34,35.
Stabilization Phase (First 1–2 Days) The focus is on treating life-threatening complications such as infections, dehydration, and electrolyte imbalances36,37.
Catch-Up Growth and Recovery Once the child tolerates therapeutic food and begins gaining weight, long-term recovery begins34.
Info
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Nutritional Rehabilitation Phase Once the child is stable, the focus shifts to gradual nutritional rebuilding34,35.
Follow-Up and Community Support After discharge, ongoing monitoring is critical to ensure sustained recovery34,42.
Info
Info
02
Marasmus
Sections like this will help you organize
02
What is it?
Marasmus is a severe form of malnutrition that primarily affects infants and young children. It is caused by a significant deficiency in caloric intake, particularly from proteins and carbohydrates43. Unlike other forms of malnutrition, marasmus leads to extreme wasting of muscle and fat tissue, giving the child a very thin, emaciated appearance with visible bones and loose skin44,45.
Signs
Visible Wasting: Severe loss of fat and muscle mass, giving the child an emaciated appearance with prominent ribs and limbs44.Low Weight-for-Height: A weight significantly below the expected range for height and age (usually < -3 SD on growth charts)46.Sunken Eyes and Loose Skin: Dehydration and fat loss can make eyes appear sunken and skin hang loosely, especially around arms, thighs, and buttocks44. Slow Growth or Stunting: Children may be significantly shorter and underdeveloped for their age due to chronic undernutrition47.
Symptoms
Lethargy and Irritability: Children with marasmus often appear tired, weak, and less responsive. Crying may be weak or absent43.Digestive Symptoms: Frequent diarrhea, bloating, or constipation due to gut damage and poor nutrient absorption48. Cold Sensitivity and Hypothermia: Lack of body fat and slowed metabolism leads to an inability to regulate temperature, even in mild climates49. Poor Appetite (in advanced cases): Although initially hungry, children may lose appetite as the body shuts down due to long-term starvation50.
ETIOLOGY (the why?)
Development
Info
Lack of Nutritional Intake (100%)
Biological & Physiological Factors
Info
Info
Enviornment
Info
Who Does Marasmus Affect?
1 in 5Under-5 Deaths
Extreme Poverty
45 Million Under 5
South Asia & Sub-Saharan Africa
Children
Death Rate
Marasmus contributes to nearly 1 in 5 deaths among children under five, often due to infections, dehydration, or organ failure made worse by extreme malnutrition64.
Marasmus represents the most severe for of wasting and affects infants and toddlers most due to their high nutritional needs62.
The highest prevalence of marasmus is in low-income areas across South Asia and Sub-Saharan Africa, where food insecurity and poor healthcare systems are most severe63.
PATHOGENESIS (the how?)
Physical Complications
Biological Responses
Cognitive Effects
Systemic Shutdown
Treatment
Next
Initial Assessment: Treatment begins with a full clinical assessment of the child’s weight-for-height ratio, visible signs of wasting, hydration status, infection risk, and comorbid conditions like diarrhea or respiratory illness77. Treatment Engagement and Outcomes: When diagnosed early and treated properly, marasmus has a high recovery potential. However, in many low-resource areas, delayed care and lack of access to therapeutic feeding lead to high mortality. Community-based treatment programs have significantly improved survival rates78. Therapeutic Approaches: Management focuses on gradual nutritional rehabilitation, rehydration, and treating infections. The goal is to stabilize, then restore weight and function without overwhelming the system. Treatments include: → Ready-to-Use Therapeutic Food (RUTF):Nutrient-dense pastes (like Plumpy'Nut) used to provide calories, protein, and micronutrients safely at home or in clinical settings79.→ Rehydration with ReSoMal:A specialized oral rehydration solution used in malnourished children to restore fluids and electrolytes without overloading sodium80.
03
Anorexia
03
What is it?
Anorexia nervosa is a severe and distinctive mental health disorder that is characterized by an overwhelming fear of gaining weight and a distorted perception of body image, leading to extreme dietary restrictions and potentially harmful behaviors like purging or excessive exercise⁸¹, ⁹⁸. The inadequate intake of food associated with anorexia results in deficiencies in both macronutrients (such as carbohydrates, proteins, and fats) and micronutrients (including essential vitamins and minerals), which can severely impair physical and mental health.
Click here to see a short film that illustrates what living with anorexia looks like.
Signs
BMI: often below 18.5 kg/m^2 in adults and under the fifth percentile for children and adolescents, is a defining characteristic ⁹³.Amenorrhea in Females: Involves the absence of at least three consecutive menstrual cycles ⁹³. Health Complications: Up to 21% of patients develop osteoporosis, over 54% experience osteopenia of the lumbar spine, and issues like irregular heart rhythms, low blood pressure, and dehydration, which may cause symptoms like blue fingers and dry skin⁸¹.
Symptoms
Fear and Behavior: Intense fear of gaining weight or becoming fat, coupled with persistent behavior that interferes with weight gain, despite being at a significantly low weight⁸¹.Physical Symptoms: Experiences of dizziness, fatigue, and even syncope (fainting)⁸¹.
2 Types of Anorexia ...
Binge-purge anorexia: involves strict food restriction combined with episodes of binge-eating followed by purging, such as vomiting or using laxatives or diuretics⁹⁷.
Restrictive anorexia: With this subtype, the person severely limits the amount and type of food they consume⁹⁷.
Development
ETIOLOGY (the why?)
Info
28%-74% Genetics
Brain structue & Function
Info
Enviornment
Info
Info
Who Does Anorexia Affect?
30 Million
10,200 aYear
0.9% of Women
Females
United States
Death Rate
This death rate equates to 1 death every 52 minutes due to anorexia. Anorexia has the highest case mortality rate of any mental illness ⁹⁵, ⁹⁹.
Adolescent and adult women are mostly at risk, with a rate of 3x higher than of those for male anorexia patients. ⁹³, ⁹⁹.
The USA leads cases of anorexia across the world, with approximately ⁹⁴.
PATHOGENESIS (the how?)
Physical Complications
Neurobiological Changes
Biological Responses
Behavioural Changes
Hormones Dystregulated:
Estrogen & Testosterone
Ghrelin
Cortisol
Insulin
T3 & T4
Next
Next
The Glucose Hormone
The Hunger Hormone
The Stress Hormone
Thyroid Hormones
Sex Hormones
Hair, Sin and Nails
Heart
Blood Flow
Digestive System
Bones
Muscular system
Next
Treatment
Initial Assessment: Anorexia nervosa assessments involve detailed interviews, exams, and tests to determine the disorder's severity, comorbid conditions, treatment history, motivation for recovery, and available supports⁹⁶.Treatment Engagement and Outcomes: A Finnish study reveals that 50% of those with anorexia do not seek treatment; yet, with proper care, at least 40% of patients, especially the young, achieve full recovery. Therapeutic Approaches: trials of outpatient psychotherapy have shown the efficacy of psychological approaches that shift focus from weight regain to enhancing quality of life. Treatments include: -->Family-Based Treatment (FBT): Focuses on involving the family in supporting the patient’s recovery ⁸⁶. -->Specialist Supportive Clinical Management (SSCM): Aims to help patients link their clinical symptoms to abnormal eating behaviors and support a gradual return to normal eating and weight ⁸⁶.
04
Bulimia
04
What is it?
Bulimia nervosa is a serious eating disorder marked by cycles of binge eating followed by purging behaviors to prevent weight gain 103. Binge eating involves consuming large amounts of food in a short period with a loss of control. Purging can involve self-induced vomiting, excessive exercise, fasting, or misuse of laxatives and diuretics. Unlike anorexia, most individuals with bulimia maintain a normal weight, making the disorder harder to detect 105. Bulimia is linked to psychological distress, including low self-esteem, anxiety, and body image concerns. These emotional struggles contribute to the cycle of disordered eating, reinforcing harmful behaviors over time 105.
Who Does Bulimia Affect?
0.9% of Women
0.3% of Men
Recovery Rates
Full Recovery and Chronic Symptoms
Men, Adolescence, or early adulthood
Females
Bulimia nervosa is more common in women, especially in teenage girls and young women 108. \ Social and cultural pressures play a role in developing body dissatisfaction, especially in industrialized societies 105.
The disorder is often underdiagnosed in men, partly due to stigma 104. Most cases emerge in adolescence or early adulthood, often between ages 12-25 108.
About 47.5% fully recover, but 26% experience chronic symptoms 110.
Behavioural and Physical Signs
Psychological Symptoms
ETIOLOGY (causes and risk factors)
The exact causes of bulimia nervosa aren't fully understood, but research suggests that neurobiological vulnerabilities play a big role in their development. These biological factors, along with environmental and developmental influences, may contribute to the onset of these eating disorders, especially during adolescence109.
Neurobiological Factors
50%-80% Genetics
Info
Environment
Info
Complications & Health Effects
The Social Mind
Dehydration
Electrolyte Imbalances
Cardiovascular
HormonalImbalances
Kidney
Skin
Gastrointestinal
Treatment and Recovery
Important Considerations in Treatment
Diagnosis of Bulimia Nervosa
Treatment Approaches for Bulimia
Treatment Outcomes & Prognosis
Quiz!
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Works Cited
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It commences as restrictive eating behaviors, driven by the desire to lose weight or control. Development of compensatory behaviors like excessive exercise, purging, or laxative use may also come into play ⁹⁷.
Developmental Risks Contributing to Anorexia:
Prematurity and Feeding Difficulties: Being born prematurely can lead to early feeding challenges, potentially causing long-term food-related issues. Personality Traits: Anxiety or perfectionism can make individuals more prone to eating disorders as they may use disordered eating to cope with stress or control aspects of their lives. Puberty Changes: Hormonal shifts and physical changes during puberty can impact self-perception and body image.
Kwashiorkor is strongly associated with oxidative stress—a state where harmful molecules called reactive oxygen species (ROS) overwhelm the body’s antioxidant defenses31. This is partly due to the deficiency of antioxidants like glutathione, vitamin E, vitamin A, selenium, and zinc, which should be replenish by meals with adequate proteins31. These deficiencies lead to damage in the membranes of cells, particularly in muscles, skin, and intestinal walls32. Additionally, elevated levels of pro-inflammatory cytokines (such as TNF-α, IL-1, and IL-6) are commonly found in affected children. These cytokines trigger edema (by increasing capillary permeability), suppress appetite, and promote muscle and fat breakdown, creating a vicious cycle of undernutrition and systemic inflammation33.
Factors Influencing Treatment Success: Symptom Severity: More severe symptoms lead to slower or incomplete recovery110. Illness Duration: Early intervention correlates with better long-term outcomes110. Co-occurring Psychiatric Conditions: Can complicate recovery and treatment effectiveness107. Treatment History: Previous unsuccessful attempts may decrease response rates110.
Recovery Rates: Short-term recovery is common, but long-term maintenance is challenging with significant relapse risk109. Continued research is necessary to refine diagnostic tools, improve treatments, and identify the most effective interventions for bulimia nervosa107.
Neurobiogical Factors
Dopamine (DA) Dysfunction:
People with AN have lower levels of dopamine metabolites in their cerebrospinal fluid (CSF), both during and after the illness.This suggests that dopamine function in certain brain areas is altered, which could affect reward processing, emotional regulation, decision-making, and food intake109.
Serotonin (5-HT) Dysfunction:
Changes in serotonin function are linked to problems with appetite, mood, and impulse control in AN and BN. Research shows these disturbances are present during the illness and can persist even after recovery. It’s thought that a pre-existing issue with serotonin may contribute to symptoms like anxiety and obsessionality, which make individuals more vulnerable to developing an eating disorder109.
Neuropeptide Alterations:
Individuals with AN often show abnormal levels of neuropeptides like CRH, NPY, beta-endorphin, and leptin when underweight. However, these levels typically return to normal after recovery, meaning they’re likely a result of malnutrition, not the cause of the disorder109.
Brain Imaging Findings:
Brain scans, such as PET and fMRI, show differences in brain activity in people with AN and BN compared to those without the disorder. These differences often involve areas of the brain that control emotions, body image, and cognitive functions109.
Digestive System
Slow digestion (gastroparesis): Food moves slowly through the stomach, causing bloating,stomach pain, and constipation ⁸⁵, ⁸⁸.Purging effects: Vomiting can erode tooth enamel and damage the esophagus, while laxative misuse can harm the colon muscles.
Developmental Risks Kwashiorkor Contribute :
Growth Demands: During early childhood, the body needs more protein to support rapid growth and development. Without enough protein, children cannot build muscle, repair tissues, or maintain healthy organs1,10.Physical and Immune Impacts: Protein deficiency leads to stunted growth, muscle wasting, and a weakened immune system. This makes children more prone to infections and delays in physical development1,3,8. Cognitive Development: Without proper nutrition, brain development can be affected. Children may experience delays in speech, movement, and learning abilities, which can have long-term consequences5,11.
In prolonged cases of marasmus, the body begins to shut down organ systems to preserve life. The heart becomes weaker, resulting in bradycardia and low cardiac output. The liver shrinks and loses its ability to store energy. Kidneys may struggle to concentrate urine, leading to dehydration and electrolyte imbalances. Gastrointestinal function slows, worsening nutrient absorption. If left untreated, this cascade of system failures can lead to multi-organ failure, coma, and death76.
Recovery Expectations: Recovery is gradual; relapses are common but manageable. Relapses provide insights for adjusting treatment110. Managing Co-Occurring Disorders: Treating anxiety, depression, and substance abuse enhances recovery success107. Patient Engagement: Patient motivation and active participation significantly impact outcomes107.
Marasmus causes visible and severe physical symptoms. These include extreme thinness, prominent bones, reduced skin elasticity, thinning hair, and dry, flaky skin. Muscle weakness and stunted growth are common, especially in children. The immune system is compromised, making infections like pneumonia or diarrhea much more dangerous. Vital signs also drop — low blood pressure, weak pulse, and hypothermia may develop. Without intervention, physical systems begin to fail, putting the individual at risk of death74.
Enviornmental Risks:
Kwashiorkor is strongly influenced by environmental conditions, particularly happens in regions affected by poverty, food insecurity, and limited access to healthcare15. Natural disasters, armed conflict, can severely disrupt food supply chains, leaving communities with diets low in protein16. In many low-income areas, traditional diets rely heavily on starchy foods like maize or cassava, which provide calories but lack essential nutrients17. Lack of nutrition education, poor sanitation, and frequent infections like diarrhea also increase the risk18. These environmental challenges are often made worse by limited government resources and underfunded health systems, making it difficult to prevent or treat malnutrition effectively15,19.
- Rehydration: Use of low-sodium oral rehydration solutions (e.g., ReSoMal) to correct dehydration safely38.
- Antibiotics: Empiric antibiotics are often given due to high infection risk, even if symptoms aren't obvious36.
- Electrolyte Correction: Supplementation with potassium, magnesium, and phosphorus is essential36.
- Avoid Iron Initially: Iron is withheld until the child is stabilized, as it can worsen infections during early treatment35,39.
Behavioural Signs Binge eating episodes: Secretive consumption of large amounts of food with a sense of loss of control; disappearance of large amounts of food 103. Frequent bathroom visits after meals: Suggestive of purging behaviors (e.g., vomiting, laxative use) 111. Excessive or compulsive exercise: Often done privately or secretly to counteract binge eating 105. Physical Signs Physical indicators of self-induced vomiting: Calluses or scars on knuckles ("Russell's sign"), swollen cheeks from enlarged salivary glands, chronic sore throat, and bloodshot eyes 111. Dental Problems: Vomiting exposes teeth to stomach acid, which can erode enamel, cause cavities, tooth sensitivity, and gum infections (gingivitis). A dental exam may reveal these issues 111. Dehydration: Purging, particularly through vomiting and laxative abuse, can cause dehydration, leading to dry mouth, fatigue, dizziness, and more serious complications111.
As the disorder progresses, complications such as bradycardia, gastrointestinal dysfunction, bone loss, and endocrine disruptions further weaken the body⁸⁵.
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Skeletal System
Weakened bones (gelatinous transformation): Lack of nutrients and calcium leads to reduced bone density (osteoporosis/osteopenia), increasing the risk of fractures ⁸⁵.Strenuous activity risk: Patients are advised to avoid intense physical activity to prevent bone injuries. Hormonal role: Reduced estrogen and testosterone levels contribute to weaker bones.
Psychotherapy Cognitive Behavioral Therapy (CBT):
Identifies and modifies negative thoughts related to eating, body image, and provides coping strategies105. Interpersonal Psychotherapy (IPT):
Improves relationships and social interactions that contribute to symptoms107. Family-Based Therapy (FBT):
Effective in adolescents, engaging the family in supporting healthy eating behaviors107. Nutritional Counseling:
Dietitian-led guidance on balanced nutrition, challenging fears about food, and correcting distorted eating beliefs107. Medication:
SSRIs (e.g., Fluoxetine [Prozac]):
Reduce binge-purge episodes; helpful for depression and anxiety106. Support Groups:
Provide community support, encouragement, and shared experiences107.
Recent studies show that children with Kwashiorkor have a disrupted gut microbiota. Gut with immature and less diverse microbial population fails to support healthy digestion, vitamin production, and immune regulation27. A key consequence is increased intestinal permeability, also known as “leaky gut,” where the gut lining becomes damaged and allows bacterial toxins (such as lipopolysaccharides) to leak into the bloodstream27. This leads to chronic low-grade inflammation, systemic immune activation, and worsened nutrient loss due to enteropathy (intestinal dysfunction). Even therapeutic feeding may be less effective without addressing the gut imbalance28.
Enviornmental Risks:
Societal pressures, including the idealization of thinness in Western culture, strongly promote dieting and excessive exercise. This influence is evident across media platforms and celebrities who often embody and endorse these ideals. Additionally, bullying and peer pressure further enforce the drive to be thin. The dieting and fitness industries exploit these standards, capitalizing on them by targeting insecurities, particularly among women, to boost their profits⁹⁶.
Starvation has profound effects on the body’s biological responses, particularly through the dysregulation of hormones that are directly involved in hunger, energy balance, and stress management. These hormonal changes originate primarily in the hypothalamus, the brain region that regulates appetite, metabolism, and energy homeostasis⁸², ⁸⁵, ⁸⁶.
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Cardiovascular System
Slow heart rate (bradycardia): The heart beats less than 60 times per minute, weakening the heart and reducing oxygen flow to the body⁸⁴, ⁸⁷, ⁹¹. This causes dizziness, fatigue, and shortness of breath. Heart failure: Prolonged starvation or improper refeeding can cause congestive heart failure, where the heart struggles to pump blood, potentially leading to sudden death.
One of the hallmarks of Kwashiorkor is hepatic steatosis, or fat accumulation in the liver29. This is caused by a shortage of essential nutrients such as choline, methionine, and cysteine, which are crucial for lipoprotein synthesis and fat export30. Without these components, fat builds up in liver cells instead of being transported to other tissues for energy use. This not only disrupts liver function (such as detoxification and protein synthesis) but also contributes to the body's inability to respond to malnutrition30. The liver’s swelling can sometimes be palpable and is a clinical indicator of disease progression1,29.
Muscular System
Muscle Wasting (Cachexia): In anorexia nervosa, chronic malnutrition and severe caloric restriction lead to the body consuming muscle tissue for energy once fat reserves are depleted, resulting in a significant loss of muscle mass and strength ⁸⁹. Impact on Health: This muscle loss weakens physical health, impairing mobility and essential bodily functions, thereby exacerbating the metabolic imbalances associated with the disorder.
When the body receives inadequate calories over time, it shifts into survival mode. Glycogen stores are quickly depleted, so the body starts breaking down fat and muscle tissue to meet its energy needs. This leads to extreme muscle wasting and fat loss, known as “wasting.” The body also suppresses growth and reproductive hormones to conserve energy. Metabolism slows drastically, and insulin, thyroid, and sex hormone levels drop. Over time, even organ tissue may be catabolized, causing serious functional decline73.
Environmental Risks Factors:
Psychological Factors: Traits like perfectionism, anxiety, obsessional thinking, and low self-esteem are common in people with BN, and these traits often appear before the eating disorder and can stick around after recovery105. Puberty and Hormonal Changes: Both AN and BN tend to develop during adolescence, around puberty. The physical and hormonal changes that happen during puberty might trigger or worsen existing vulnerabilities, especially in females109. Stress and Societal Pressures: Stress can heighten anxiety and obsessional behaviors. Cultural pressures, especially in industrialized societies, can contribute to body image dissatisfaction and disordered eating habits105. Family Environment: A family history of mental health issues, including eating disorders, depression, and substance abuse, can increase the risk. Family dynamics—such as parental conflicts, criticism, or a lack of involvement—may also contribute to the development of these disorders112.
Enviornmental Risk Contributing to Marasmus:
Poverty:Limited access to nutritious food, clean water, and healthcare means children often go without the essentials needed for growth and development58. Natural Disasters & Conflict: Crises like drought, war, or displacement can interrupt food supply and healthcare access, leading to chronic undernutrition in vulnerable populations59. Neglect & Poor Sanitation: Unclean living conditions and lack of proper care increase the risk of infections, which lower appetite and reduce nutrient absorption — worsening malnutrition60.
- Regular Weight Checks and growth monitoring34.
- Nutrition Programs and Food Security Support, especially in communities affected by poverty or famine15,22.
- Integration with Public Health Services to address underlying environmental and social issues contributing to malnutrition19,22.
Gastrointestinal Complications
Constipation and Hemorrhoids: Misusing laxatives can disrupt normal bowel function, leading to chronic constipation, laxative dependence, and hemorrhoids111. Pancreatic Damage: Bulimia can cause inflammation in the pancreas (pancreatitis) due to frequent vomiting or laxative misuse, a serious and painful condition111.
Esophageal Damage: Frequent vomiting can irritate the esophagus, leading to inflammation and potential permanent damage. This can cause heartburn, pain, trouble swallowing, and an increased risk of esophageal tears (Mallory-Weiss tears), which can cause bleeding111.Dental Problems: Stomach acid from vomiting can erode tooth enamel, leading to cavities, gum infections (gingivitis), and increased tooth sensitivity. Over time, the enamel can wear down, changing the appearance of the teeth111. Stomach Rupture: Although rare, forceful vomiting can tear the stomach wall, which is a life-threatening emergency requiring immediate medical care111.
Hair, Skin and Nails
Lanugo hair growth: Fine hair grows on the body (upper lip, arms, back) to retain heat. Hair loss: Scalp hair thins or falls out due to lack of nutrients. Brittle nails: Nails become fragile and break easily ⁸³, ⁹².
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Differences in the Brain:
Structure:
Function:
Slowed Cognitive Processing: Due to poor brain nourishment, children may experience slower thinking, learning difficulties, and trouble with attention and memory. These changes are linked to disruptions in neural connections like myelin damage and atrophy in cerebral11,13. Emotional and Behavioral Changes:Kwashiorkor can lead to irritability, apathy, and reduced responsiveness. These symptoms may be related to functional disruptions in areas of the brain that regulate mood and emotional behavior, likely influenced by inflammation and nutrient imbalances in the brain5,14.
Cerebral Atrophy: Children with Kwashiorkor often show reduced brain size, also known as cerebral atrophy, due to the lack of protein and essential nutrients needed for brain development. This can result in smaller brain volume, particularly in the cerebral cortex, which is responsible for thinking, memory, and decision-making11,12.Myelin Damage:Protein deficiency affects the formation and maintenance of myelin, the protective coating around nerve fibers. Damage to myelin can slow down brain communication and lead to delays in cognitive and motor function development11,13.
- High-Protein Diet: Slowly reintroduce more protein-rich foods to restore muscle mass and organ function1,40.
- Psychosocial Support: Emotional and cognitive stimulation is important, especially in young children who may have developmental delays11,42.
- Parental Education: Teach caregivers about balanced nutrition, breastfeeding, hygiene, and how to prevent relapse42.
- Therapeutic Feeding: Introduction of F-75 formula (low protein and low calorie) followed by F-100 (higher energy and protein) or Ready-to-Use Therapeutic Food (RUTF) like Plumpy’Nut35,40.
- Small, Frequent Meals: To prevent refeeding syndrome and allow the body to adjust to food intake34.
- Micronutrient Supplementation: Provide vitamins and minerals such as zinc, vitamin A, folic acid, and others to restore cellular function33,36,41.
Psychological and Emotional Symptoms Distorted Body Image: People with bulimia often have a warped view of their body shape and size. They may feel overweight even when they are at a normal or low weight 105. Fear of Weight Gain: There is an intense fear of gaining weight, leading individuals to take extreme measures to prevent it 103. Preoccupation with Food, Weight, and Shape: Thoughts about food, weight, and body shape dominate their thoughts, affecting their mood and self-esteem105. Secrecy and Shame: Many try to hide their bingeing and purging behaviors due to shame 107. Mood Swings: Bulimia can be linked to irritability, mood swings, and emotional instability 105. Depression and Anxiety: Individuals with bulimia often experience depression, anxiety, and low self-esteem, which can be present before or develop because of the eating disorder 107. Social Isolation: Feelings of shame and guilt often lead to social withdrawal107. Substance Abuse: Bulimia may co-occur with substance abuse issues, like alcohol or drug use110.
Physical Examination:
- Checks weight, vital signs, dental erosion, knuckle calluses (Russell’s sign), and salivary gland swelling.
- Reviews medical history, eating habits, and purging behaviors103.
Psychological Evaluation:
- Assesses thoughts, emotions, and behaviors related to food, body image, anxiety, and depression103.
DSM-5 Criteria:
- Recurrent binge episodes with a lack of control.
- Recurrent compensatory behaviors (vomiting, laxatives, exercise).
- Self-esteem heavily influenced by body shape and weight103.
Laboratory Tests:
- Blood tests for electrolyte imbalances (e.g., low potassium), dehydration, and kidney function111.
Blood Flow
Cold intolerance and blue-tinted extremities: Starvation slows blood flow, causing fingers and ears to appear bluish and making individuals feel cold ⁸⁶.
Changes in reward pathways can make food restriction temporarily relieve anxiety by altering dopamine and serotonin levels. Prolonged malnutrition can lead to brain atrophy, especially in areas managing emotions, reward processing, and self-awareness. Losing weight and controlling food intake might briefly boost self-esteem and lessen anxiety, reinforcing unhealthy behaviors ⁸⁹.
Kwashiorkor is mainly caused by a lack of protein in the diet, even if calorie intake from carbs is sufficient. Without protein, the body can’t build or repair tissues, leading to muscle wasting, edema, and weakened immunity1,2.
Anorexia nervosa often appears to have familial ties, with heritability estimates varying between 28% and 74%. Despite this, the genetic underpinnings of the disorder remain elusive. To date, two large-scale genetic studies, specifically genome-wide association studies (GWAS), have been carried out but they have yet to identify the individual gene associated ⁸², ⁹⁶.
Although marasmus does not directly affect the brain like a neurological disease, chronic malnutrition during critical developmental periods can impair brain growth. Children may show delayed milestones such as sitting, walking, or speaking. Long-term deficits in memory, learning ability, and attention span are commonly observed. The lack of nutrients affects neurotransmitter production and brain plasticity, reducing the capacity for emotional regulation and cognitive flexibility75.
Differences in the Brain:
Structure:
Function:
Orbitofrontal cortex: Involved in reward processing, particularly related to food. This area is larger in people with anorexia, possibly contributing to altered food perceptions¹⁰². Insula: Linked to self-awareness and understanding internal body signals. Increased size in people with anorexia may affect body perception and hunger regulation¹⁰².
Distorted body image involves two brain networks:Parietal Network: This area integrates sensory information and helps accurately perceive one's body size and shape. Dysfunctions here can lead to distorted perceptions, such as seeing body parts as larger or smaller than they are¹⁰². Prefrontal-Insula-Amygdala Network: Manages emotional responses to how one views their body, affecting feelings about appearance¹⁰².
🍼 Inadequate Energy IntakeMarasmus results from a chronic deficiency in calories, particularly from carbohydrates, fats, and proteins. This is almost always due to prolonged undernourishment rather than a specific genetic cause61.
Physical and Biological Factors Contributing to Marasmus:
High Metabolic Demands: Infants require high energy for rapid growth; marasmus occurs when intake doesn’t meet demand54. Compromised Immunity: Undernutrition weakens the immune system, increasing infection risk and nutrient loss55. Gut Malabsorption: Chronic malnutrition damages the intestinal lining (villous atrophy), making nutrient absorption harder56. Micronutrient Deficiencies: Lack of essential vitamins/minerals (e.g. iron, zinc, vitamin A) worsens health outcomes57.
In Kwashiorkor, the body experiences metabolic inflexibility, meaning it cannot effectively switch to using available energy sources when under nutritional stress24. Unlike marasmus (another form of severe malnutrition), children with Kwashiorkor have impaired activation of key survival pathways, including autophagy (the recycling of damaged cell components) and the unfolded protein response in the endoplasmic reticulum25. This leads to cellular stress, dysfunction, and damage, especially in organs like the liver and pancreas26. The suppression of protein synthesis and inadequate stress responses contribute to muscle breakdown, poor wound healing, and immune suppression3,26.
Developmental Risks Contributing to Marasmus:
Premature Weaning: Switching from breast milk too early, especially without nutrient-dense alternatives51. Repeated Infections: Chronic illnesses (e.g. diarrhea, malaria) increase nutritional demands and reduce nutrient absorption52. Low Birth Weight: Infants born small may already have reduced energy reserves53.
Developmental Risks Kwashiorkor Contribute :
Growth Demands: During early childhood, the body needs more protein to support rapid growth and development. Without enough protein, children cannot build muscle, repair tissues, or maintain healthy organs1,10.Physical and Immune Impacts: Protein deficiency leads to stunted growth, muscle wasting, and a weakened immune system. This makes children more prone to infections and delays in physical development1,3,8. Cognitive Development: Without proper nutrition, brain development can be affected. Children may experience delays in speech, movement, and learning abilities, which can have long-term consequences5,11.
Differences in the Brain:
Structure:
Function:
Slowed Cognitive Processing: Due to poor brain nourishment, children may experience slower thinking, learning difficulties, and trouble with attention and memory. These changes are linked to disruptions in neural connections like myelin damage and atrophy in cerebral11,13. Emotional and Behavioral Changes:Kwashiorkor can lead to irritability, apathy, and reduced responsiveness. These symptoms may be related to functional disruptions in areas of the brain that regulate mood and emotional behavior, likely influenced by inflammation and nutrient imbalances in the brain5,14.
Cerebral Atrophy: Children with Kwashiorkor often show reduced brain size, also known as cerebral atrophy, due to the lack of protein and essential nutrients needed for brain development. This can result in smaller brain volume, particularly in the cerebral cortex, which is responsible for thinking, memory, and decision-making11,12.Myelin Damage:Protein deficiency affects the formation and maintenance of myelin, the protective coating around nerve fibers. Damage to myelin can slow down brain communication and lead to delays in cognitive and motor function development11,13.
Kwashiorkor is mainly caused by a lack of protein in the diet, even if calorie intake from carbs is sufficient. Without protein, the body can’t build or repair tissues, leading to muscle wasting, edema, and weakened immunity1,2.
Enviornmental Risks:
Kwashiorkor is strongly influenced by environmental conditions, particularly happens in regions affected by poverty, food insecurity, and limited access to healthcare15. Natural disasters, armed conflict, can severely disrupt food supply chains, leaving communities with diets low in protein16. In many low-income areas, traditional diets rely heavily on starchy foods like maize or cassava, which provide calories but lack essential nutrients17. Lack of nutrition education, poor sanitation, and frequent infections like diarrhea also increase the risk18. These environmental challenges are often made worse by limited government resources and underfunded health systems, making it difficult to prevent or treat malnutrition effectively15,19.
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Transcript
Fueling Life: A Clinical Look at Macronutrient Deficiency Disorders
A course dedicated to educating others about the causes, consequences, and prevention of macronutrient deficiencies.
Start
What Are Macronutrient Deficines?
You are what you eat — and what you don’t eat can hurt you.Macronutrient deficiencies occur when the body doesn’t receive enough of the three key nutrients it needs in large amounts: carbohydrates, proteins, and fats. These nutrients are essential for energy, growth, repair, and survival. A lack of any one macronutrient can lead to serious health consequences, especially in vulnerable populations like children. This course will explore the causes, symptoms, and real-life impacts of macronutrient deficiencies — including severe conditions like kwashiorkor, marasmus, anorexia and bulimia
Next
Module Breakdown:
Marasmus
Kwashiorkor
Bulimia
Anorexia
Works Cited
Quiz
01
Kwashiorkor
01
What is it?
Kwashiorkor is a form of severe malnutrition that happens when the body doesn't get enough protein, even if it gets enough calories. It mostly affects young children, especially in areas where food source is scarce. Common signs include a swollen belly, thin muscles, irritability, and changes in skin and hair. Without proper treatment, kwashiorkor can be life-threatening. It’s important to understand this condition so we can recognize and help prevent it1,2.
Signs
Swelling (Edema) & Enlarged Abdomen: Swelling in feet, legs, and sometimes the face. The belly may appear bloated or puffy because of fluid buildup and weak abdominal muscles3. Changes in Hair and Skin: Hair may become thin, brittle, and change color (often reddish or yellowish). Skin may develop dark patches, cracks, or become flaky4. Irritability and Behavioral Changes: Children may seem fussy, anxious, or withdrawn5. Slow Growth and Weight Gain: Children often stop growing properly and may not gain weight as expected for their age6.
Symptoms
Fatigue and Weakness: Children may seem constantly tired, have little energy, and struggle with physical activity2.Loss of Muscle Mass: Muscle wasting may occur, especially in the arms and legs, although the swelling can hide this3. Poor Appetite: Unlike other forms of malnutrition, children with kwashiorkor may not feel hungry7. Infections: A weakened immune system increases the risk of frequent or severe infections8. Slow Wound Healing: Cuts and sores may heal slowly due to poor nutrition and reduced protein levels9.
ETIOLOGY (the why?)
Development
Info
100% Severe Protein Deficiency
Brain structue & Function
Info
Info
Enviornment
Info
ETIOLOGY (the why?)
Development
Info
100% Severe Protein Deficiency
Brain structue & Function
Info
Info
Enviornment
Info
Who Does Kwashiorkor Affect?
Poverty
1.7 Million
Children
Young children between 1-5 years old
Sub-Saharan Africa & South Asia
Globally/Anually
The highest number of cases are found in low-income regions, particularly in Sub-Saharan Africa, South Asia, and parts of Central America, where access to protein-rich foods is limited due to poverty, drought, or conflict15,16,22
Over 1.7 million children suffer from severe acute malnutrition with edema—a hallmark of Kwashiorkor—every year. Without treatment, it can lead to long-term developmental issues or death21.
Especially children during or after the weaning period. Their bodies need more protein for growth, making them especially vulnerable to deficiency.1,10,20
PATHOGENESIS (the how?)
Oxidative Stress & Inflammation
Fatty Liver Development
Gut Microbiome Disruption
Metabolic Failure
Next
Treatment
Treating kwashiorkor requires a careful, staged approach to correct nutritional deficiencies, manage complications, and support long-term recovery. Sudden or aggressive feeding can be dangerous, so treatment must be gradual and closely monitored34,35.
Stabilization Phase (First 1–2 Days) The focus is on treating life-threatening complications such as infections, dehydration, and electrolyte imbalances36,37.
Catch-Up Growth and Recovery Once the child tolerates therapeutic food and begins gaining weight, long-term recovery begins34.
Info
Info
Nutritional Rehabilitation Phase Once the child is stable, the focus shifts to gradual nutritional rebuilding34,35.
Follow-Up and Community Support After discharge, ongoing monitoring is critical to ensure sustained recovery34,42.
Info
Info
02
Marasmus
Sections like this will help you organize
02
What is it?
Marasmus is a severe form of malnutrition that primarily affects infants and young children. It is caused by a significant deficiency in caloric intake, particularly from proteins and carbohydrates43. Unlike other forms of malnutrition, marasmus leads to extreme wasting of muscle and fat tissue, giving the child a very thin, emaciated appearance with visible bones and loose skin44,45.
Signs
Visible Wasting: Severe loss of fat and muscle mass, giving the child an emaciated appearance with prominent ribs and limbs44.Low Weight-for-Height: A weight significantly below the expected range for height and age (usually < -3 SD on growth charts)46.Sunken Eyes and Loose Skin: Dehydration and fat loss can make eyes appear sunken and skin hang loosely, especially around arms, thighs, and buttocks44. Slow Growth or Stunting: Children may be significantly shorter and underdeveloped for their age due to chronic undernutrition47.
Symptoms
Lethargy and Irritability: Children with marasmus often appear tired, weak, and less responsive. Crying may be weak or absent43.Digestive Symptoms: Frequent diarrhea, bloating, or constipation due to gut damage and poor nutrient absorption48. Cold Sensitivity and Hypothermia: Lack of body fat and slowed metabolism leads to an inability to regulate temperature, even in mild climates49. Poor Appetite (in advanced cases): Although initially hungry, children may lose appetite as the body shuts down due to long-term starvation50.
ETIOLOGY (the why?)
Development
Info
Lack of Nutritional Intake (100%)
Biological & Physiological Factors
Info
Info
Enviornment
Info
Who Does Marasmus Affect?
1 in 5Under-5 Deaths
Extreme Poverty
45 Million Under 5
South Asia & Sub-Saharan Africa
Children
Death Rate
Marasmus contributes to nearly 1 in 5 deaths among children under five, often due to infections, dehydration, or organ failure made worse by extreme malnutrition64.
Marasmus represents the most severe for of wasting and affects infants and toddlers most due to their high nutritional needs62.
The highest prevalence of marasmus is in low-income areas across South Asia and Sub-Saharan Africa, where food insecurity and poor healthcare systems are most severe63.
PATHOGENESIS (the how?)
Physical Complications
Biological Responses
Cognitive Effects
Systemic Shutdown
Treatment
Next
Initial Assessment: Treatment begins with a full clinical assessment of the child’s weight-for-height ratio, visible signs of wasting, hydration status, infection risk, and comorbid conditions like diarrhea or respiratory illness77. Treatment Engagement and Outcomes: When diagnosed early and treated properly, marasmus has a high recovery potential. However, in many low-resource areas, delayed care and lack of access to therapeutic feeding lead to high mortality. Community-based treatment programs have significantly improved survival rates78. Therapeutic Approaches: Management focuses on gradual nutritional rehabilitation, rehydration, and treating infections. The goal is to stabilize, then restore weight and function without overwhelming the system. Treatments include: → Ready-to-Use Therapeutic Food (RUTF):Nutrient-dense pastes (like Plumpy'Nut) used to provide calories, protein, and micronutrients safely at home or in clinical settings79.→ Rehydration with ReSoMal:A specialized oral rehydration solution used in malnourished children to restore fluids and electrolytes without overloading sodium80.
03
Anorexia
03
What is it?
Anorexia nervosa is a severe and distinctive mental health disorder that is characterized by an overwhelming fear of gaining weight and a distorted perception of body image, leading to extreme dietary restrictions and potentially harmful behaviors like purging or excessive exercise⁸¹, ⁹⁸. The inadequate intake of food associated with anorexia results in deficiencies in both macronutrients (such as carbohydrates, proteins, and fats) and micronutrients (including essential vitamins and minerals), which can severely impair physical and mental health.
Click here to see a short film that illustrates what living with anorexia looks like.
Signs
BMI: often below 18.5 kg/m^2 in adults and under the fifth percentile for children and adolescents, is a defining characteristic ⁹³.Amenorrhea in Females: Involves the absence of at least three consecutive menstrual cycles ⁹³. Health Complications: Up to 21% of patients develop osteoporosis, over 54% experience osteopenia of the lumbar spine, and issues like irregular heart rhythms, low blood pressure, and dehydration, which may cause symptoms like blue fingers and dry skin⁸¹.
Symptoms
Fear and Behavior: Intense fear of gaining weight or becoming fat, coupled with persistent behavior that interferes with weight gain, despite being at a significantly low weight⁸¹.Physical Symptoms: Experiences of dizziness, fatigue, and even syncope (fainting)⁸¹.
2 Types of Anorexia ...
Binge-purge anorexia: involves strict food restriction combined with episodes of binge-eating followed by purging, such as vomiting or using laxatives or diuretics⁹⁷.
Restrictive anorexia: With this subtype, the person severely limits the amount and type of food they consume⁹⁷.
Development
ETIOLOGY (the why?)
Info
28%-74% Genetics
Brain structue & Function
Info
Enviornment
Info
Info
Who Does Anorexia Affect?
30 Million
10,200 aYear
0.9% of Women
Females
United States
Death Rate
This death rate equates to 1 death every 52 minutes due to anorexia. Anorexia has the highest case mortality rate of any mental illness ⁹⁵, ⁹⁹.
Adolescent and adult women are mostly at risk, with a rate of 3x higher than of those for male anorexia patients. ⁹³, ⁹⁹.
The USA leads cases of anorexia across the world, with approximately ⁹⁴.
PATHOGENESIS (the how?)
Physical Complications
Neurobiological Changes
Biological Responses
Behavioural Changes
Hormones Dystregulated:
Estrogen & Testosterone
Ghrelin
Cortisol
Insulin
T3 & T4
Next
Next
The Glucose Hormone
The Hunger Hormone
The Stress Hormone
Thyroid Hormones
Sex Hormones
Hair, Sin and Nails
Heart
Blood Flow
Digestive System
Bones
Muscular system
Next
Treatment
Initial Assessment: Anorexia nervosa assessments involve detailed interviews, exams, and tests to determine the disorder's severity, comorbid conditions, treatment history, motivation for recovery, and available supports⁹⁶.Treatment Engagement and Outcomes: A Finnish study reveals that 50% of those with anorexia do not seek treatment; yet, with proper care, at least 40% of patients, especially the young, achieve full recovery. Therapeutic Approaches: trials of outpatient psychotherapy have shown the efficacy of psychological approaches that shift focus from weight regain to enhancing quality of life. Treatments include: -->Family-Based Treatment (FBT): Focuses on involving the family in supporting the patient’s recovery ⁸⁶. -->Specialist Supportive Clinical Management (SSCM): Aims to help patients link their clinical symptoms to abnormal eating behaviors and support a gradual return to normal eating and weight ⁸⁶.
04
Bulimia
04
What is it?
Bulimia nervosa is a serious eating disorder marked by cycles of binge eating followed by purging behaviors to prevent weight gain 103. Binge eating involves consuming large amounts of food in a short period with a loss of control. Purging can involve self-induced vomiting, excessive exercise, fasting, or misuse of laxatives and diuretics. Unlike anorexia, most individuals with bulimia maintain a normal weight, making the disorder harder to detect 105. Bulimia is linked to psychological distress, including low self-esteem, anxiety, and body image concerns. These emotional struggles contribute to the cycle of disordered eating, reinforcing harmful behaviors over time 105.
Who Does Bulimia Affect?
0.9% of Women
0.3% of Men
Recovery Rates
Full Recovery and Chronic Symptoms
Men, Adolescence, or early adulthood
Females
Bulimia nervosa is more common in women, especially in teenage girls and young women 108. \ Social and cultural pressures play a role in developing body dissatisfaction, especially in industrialized societies 105.
The disorder is often underdiagnosed in men, partly due to stigma 104. Most cases emerge in adolescence or early adulthood, often between ages 12-25 108.
About 47.5% fully recover, but 26% experience chronic symptoms 110.
Behavioural and Physical Signs
Psychological Symptoms
ETIOLOGY (causes and risk factors)
The exact causes of bulimia nervosa aren't fully understood, but research suggests that neurobiological vulnerabilities play a big role in their development. These biological factors, along with environmental and developmental influences, may contribute to the onset of these eating disorders, especially during adolescence109.
Neurobiological Factors
50%-80% Genetics
Info
Environment
Info
Complications & Health Effects
The Social Mind
Dehydration
Electrolyte Imbalances
Cardiovascular
HormonalImbalances
Kidney
Skin
Gastrointestinal
Treatment and Recovery
Important Considerations in Treatment
Diagnosis of Bulimia Nervosa
Treatment Approaches for Bulimia
Treatment Outcomes & Prognosis
Quiz!
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Works Cited
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It commences as restrictive eating behaviors, driven by the desire to lose weight or control. Development of compensatory behaviors like excessive exercise, purging, or laxative use may also come into play ⁹⁷.
Developmental Risks Contributing to Anorexia:
Prematurity and Feeding Difficulties: Being born prematurely can lead to early feeding challenges, potentially causing long-term food-related issues. Personality Traits: Anxiety or perfectionism can make individuals more prone to eating disorders as they may use disordered eating to cope with stress or control aspects of their lives. Puberty Changes: Hormonal shifts and physical changes during puberty can impact self-perception and body image.
Kwashiorkor is strongly associated with oxidative stress—a state where harmful molecules called reactive oxygen species (ROS) overwhelm the body’s antioxidant defenses31. This is partly due to the deficiency of antioxidants like glutathione, vitamin E, vitamin A, selenium, and zinc, which should be replenish by meals with adequate proteins31. These deficiencies lead to damage in the membranes of cells, particularly in muscles, skin, and intestinal walls32. Additionally, elevated levels of pro-inflammatory cytokines (such as TNF-α, IL-1, and IL-6) are commonly found in affected children. These cytokines trigger edema (by increasing capillary permeability), suppress appetite, and promote muscle and fat breakdown, creating a vicious cycle of undernutrition and systemic inflammation33.
Factors Influencing Treatment Success: Symptom Severity: More severe symptoms lead to slower or incomplete recovery110. Illness Duration: Early intervention correlates with better long-term outcomes110. Co-occurring Psychiatric Conditions: Can complicate recovery and treatment effectiveness107. Treatment History: Previous unsuccessful attempts may decrease response rates110.
Recovery Rates: Short-term recovery is common, but long-term maintenance is challenging with significant relapse risk109. Continued research is necessary to refine diagnostic tools, improve treatments, and identify the most effective interventions for bulimia nervosa107.
Neurobiogical Factors
Dopamine (DA) Dysfunction:
People with AN have lower levels of dopamine metabolites in their cerebrospinal fluid (CSF), both during and after the illness.This suggests that dopamine function in certain brain areas is altered, which could affect reward processing, emotional regulation, decision-making, and food intake109.
Serotonin (5-HT) Dysfunction:
Changes in serotonin function are linked to problems with appetite, mood, and impulse control in AN and BN. Research shows these disturbances are present during the illness and can persist even after recovery. It’s thought that a pre-existing issue with serotonin may contribute to symptoms like anxiety and obsessionality, which make individuals more vulnerable to developing an eating disorder109.
Neuropeptide Alterations:
Individuals with AN often show abnormal levels of neuropeptides like CRH, NPY, beta-endorphin, and leptin when underweight. However, these levels typically return to normal after recovery, meaning they’re likely a result of malnutrition, not the cause of the disorder109.
Brain Imaging Findings:
Brain scans, such as PET and fMRI, show differences in brain activity in people with AN and BN compared to those without the disorder. These differences often involve areas of the brain that control emotions, body image, and cognitive functions109.
Digestive System
Slow digestion (gastroparesis): Food moves slowly through the stomach, causing bloating,stomach pain, and constipation ⁸⁵, ⁸⁸.Purging effects: Vomiting can erode tooth enamel and damage the esophagus, while laxative misuse can harm the colon muscles.
Developmental Risks Kwashiorkor Contribute :
Growth Demands: During early childhood, the body needs more protein to support rapid growth and development. Without enough protein, children cannot build muscle, repair tissues, or maintain healthy organs1,10.Physical and Immune Impacts: Protein deficiency leads to stunted growth, muscle wasting, and a weakened immune system. This makes children more prone to infections and delays in physical development1,3,8. Cognitive Development: Without proper nutrition, brain development can be affected. Children may experience delays in speech, movement, and learning abilities, which can have long-term consequences5,11.
In prolonged cases of marasmus, the body begins to shut down organ systems to preserve life. The heart becomes weaker, resulting in bradycardia and low cardiac output. The liver shrinks and loses its ability to store energy. Kidneys may struggle to concentrate urine, leading to dehydration and electrolyte imbalances. Gastrointestinal function slows, worsening nutrient absorption. If left untreated, this cascade of system failures can lead to multi-organ failure, coma, and death76.
Recovery Expectations: Recovery is gradual; relapses are common but manageable. Relapses provide insights for adjusting treatment110. Managing Co-Occurring Disorders: Treating anxiety, depression, and substance abuse enhances recovery success107. Patient Engagement: Patient motivation and active participation significantly impact outcomes107.
Marasmus causes visible and severe physical symptoms. These include extreme thinness, prominent bones, reduced skin elasticity, thinning hair, and dry, flaky skin. Muscle weakness and stunted growth are common, especially in children. The immune system is compromised, making infections like pneumonia or diarrhea much more dangerous. Vital signs also drop — low blood pressure, weak pulse, and hypothermia may develop. Without intervention, physical systems begin to fail, putting the individual at risk of death74.
Enviornmental Risks:
Kwashiorkor is strongly influenced by environmental conditions, particularly happens in regions affected by poverty, food insecurity, and limited access to healthcare15. Natural disasters, armed conflict, can severely disrupt food supply chains, leaving communities with diets low in protein16. In many low-income areas, traditional diets rely heavily on starchy foods like maize or cassava, which provide calories but lack essential nutrients17. Lack of nutrition education, poor sanitation, and frequent infections like diarrhea also increase the risk18. These environmental challenges are often made worse by limited government resources and underfunded health systems, making it difficult to prevent or treat malnutrition effectively15,19.
Behavioural Signs Binge eating episodes: Secretive consumption of large amounts of food with a sense of loss of control; disappearance of large amounts of food 103. Frequent bathroom visits after meals: Suggestive of purging behaviors (e.g., vomiting, laxative use) 111. Excessive or compulsive exercise: Often done privately or secretly to counteract binge eating 105. Physical Signs Physical indicators of self-induced vomiting: Calluses or scars on knuckles ("Russell's sign"), swollen cheeks from enlarged salivary glands, chronic sore throat, and bloodshot eyes 111. Dental Problems: Vomiting exposes teeth to stomach acid, which can erode enamel, cause cavities, tooth sensitivity, and gum infections (gingivitis). A dental exam may reveal these issues 111. Dehydration: Purging, particularly through vomiting and laxative abuse, can cause dehydration, leading to dry mouth, fatigue, dizziness, and more serious complications111.
As the disorder progresses, complications such as bradycardia, gastrointestinal dysfunction, bone loss, and endocrine disruptions further weaken the body⁸⁵.
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Skeletal System
Weakened bones (gelatinous transformation): Lack of nutrients and calcium leads to reduced bone density (osteoporosis/osteopenia), increasing the risk of fractures ⁸⁵.Strenuous activity risk: Patients are advised to avoid intense physical activity to prevent bone injuries. Hormonal role: Reduced estrogen and testosterone levels contribute to weaker bones.
Psychotherapy Cognitive Behavioral Therapy (CBT): Identifies and modifies negative thoughts related to eating, body image, and provides coping strategies105. Interpersonal Psychotherapy (IPT): Improves relationships and social interactions that contribute to symptoms107. Family-Based Therapy (FBT): Effective in adolescents, engaging the family in supporting healthy eating behaviors107. Nutritional Counseling: Dietitian-led guidance on balanced nutrition, challenging fears about food, and correcting distorted eating beliefs107. Medication: SSRIs (e.g., Fluoxetine [Prozac]): Reduce binge-purge episodes; helpful for depression and anxiety106. Support Groups: Provide community support, encouragement, and shared experiences107.
Recent studies show that children with Kwashiorkor have a disrupted gut microbiota. Gut with immature and less diverse microbial population fails to support healthy digestion, vitamin production, and immune regulation27. A key consequence is increased intestinal permeability, also known as “leaky gut,” where the gut lining becomes damaged and allows bacterial toxins (such as lipopolysaccharides) to leak into the bloodstream27. This leads to chronic low-grade inflammation, systemic immune activation, and worsened nutrient loss due to enteropathy (intestinal dysfunction). Even therapeutic feeding may be less effective without addressing the gut imbalance28.
Enviornmental Risks:
Societal pressures, including the idealization of thinness in Western culture, strongly promote dieting and excessive exercise. This influence is evident across media platforms and celebrities who often embody and endorse these ideals. Additionally, bullying and peer pressure further enforce the drive to be thin. The dieting and fitness industries exploit these standards, capitalizing on them by targeting insecurities, particularly among women, to boost their profits⁹⁶.
Starvation has profound effects on the body’s biological responses, particularly through the dysregulation of hormones that are directly involved in hunger, energy balance, and stress management. These hormonal changes originate primarily in the hypothalamus, the brain region that regulates appetite, metabolism, and energy homeostasis⁸², ⁸⁵, ⁸⁶.
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Cardiovascular System
Slow heart rate (bradycardia): The heart beats less than 60 times per minute, weakening the heart and reducing oxygen flow to the body⁸⁴, ⁸⁷, ⁹¹. This causes dizziness, fatigue, and shortness of breath. Heart failure: Prolonged starvation or improper refeeding can cause congestive heart failure, where the heart struggles to pump blood, potentially leading to sudden death.
One of the hallmarks of Kwashiorkor is hepatic steatosis, or fat accumulation in the liver29. This is caused by a shortage of essential nutrients such as choline, methionine, and cysteine, which are crucial for lipoprotein synthesis and fat export30. Without these components, fat builds up in liver cells instead of being transported to other tissues for energy use. This not only disrupts liver function (such as detoxification and protein synthesis) but also contributes to the body's inability to respond to malnutrition30. The liver’s swelling can sometimes be palpable and is a clinical indicator of disease progression1,29.
Muscular System
Muscle Wasting (Cachexia): In anorexia nervosa, chronic malnutrition and severe caloric restriction lead to the body consuming muscle tissue for energy once fat reserves are depleted, resulting in a significant loss of muscle mass and strength ⁸⁹. Impact on Health: This muscle loss weakens physical health, impairing mobility and essential bodily functions, thereby exacerbating the metabolic imbalances associated with the disorder.
When the body receives inadequate calories over time, it shifts into survival mode. Glycogen stores are quickly depleted, so the body starts breaking down fat and muscle tissue to meet its energy needs. This leads to extreme muscle wasting and fat loss, known as “wasting.” The body also suppresses growth and reproductive hormones to conserve energy. Metabolism slows drastically, and insulin, thyroid, and sex hormone levels drop. Over time, even organ tissue may be catabolized, causing serious functional decline73.
Environmental Risks Factors:
Psychological Factors: Traits like perfectionism, anxiety, obsessional thinking, and low self-esteem are common in people with BN, and these traits often appear before the eating disorder and can stick around after recovery105. Puberty and Hormonal Changes: Both AN and BN tend to develop during adolescence, around puberty. The physical and hormonal changes that happen during puberty might trigger or worsen existing vulnerabilities, especially in females109. Stress and Societal Pressures: Stress can heighten anxiety and obsessional behaviors. Cultural pressures, especially in industrialized societies, can contribute to body image dissatisfaction and disordered eating habits105. Family Environment: A family history of mental health issues, including eating disorders, depression, and substance abuse, can increase the risk. Family dynamics—such as parental conflicts, criticism, or a lack of involvement—may also contribute to the development of these disorders112.
Enviornmental Risk Contributing to Marasmus:
Poverty:Limited access to nutritious food, clean water, and healthcare means children often go without the essentials needed for growth and development58. Natural Disasters & Conflict: Crises like drought, war, or displacement can interrupt food supply and healthcare access, leading to chronic undernutrition in vulnerable populations59. Neglect & Poor Sanitation: Unclean living conditions and lack of proper care increase the risk of infections, which lower appetite and reduce nutrient absorption — worsening malnutrition60.
Gastrointestinal Complications
Constipation and Hemorrhoids: Misusing laxatives can disrupt normal bowel function, leading to chronic constipation, laxative dependence, and hemorrhoids111. Pancreatic Damage: Bulimia can cause inflammation in the pancreas (pancreatitis) due to frequent vomiting or laxative misuse, a serious and painful condition111.
Esophageal Damage: Frequent vomiting can irritate the esophagus, leading to inflammation and potential permanent damage. This can cause heartburn, pain, trouble swallowing, and an increased risk of esophageal tears (Mallory-Weiss tears), which can cause bleeding111.Dental Problems: Stomach acid from vomiting can erode tooth enamel, leading to cavities, gum infections (gingivitis), and increased tooth sensitivity. Over time, the enamel can wear down, changing the appearance of the teeth111. Stomach Rupture: Although rare, forceful vomiting can tear the stomach wall, which is a life-threatening emergency requiring immediate medical care111.
Hair, Skin and Nails
Lanugo hair growth: Fine hair grows on the body (upper lip, arms, back) to retain heat. Hair loss: Scalp hair thins or falls out due to lack of nutrients. Brittle nails: Nails become fragile and break easily ⁸³, ⁹².
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Differences in the Brain:
Structure:
Function:
Slowed Cognitive Processing: Due to poor brain nourishment, children may experience slower thinking, learning difficulties, and trouble with attention and memory. These changes are linked to disruptions in neural connections like myelin damage and atrophy in cerebral11,13. Emotional and Behavioral Changes:Kwashiorkor can lead to irritability, apathy, and reduced responsiveness. These symptoms may be related to functional disruptions in areas of the brain that regulate mood and emotional behavior, likely influenced by inflammation and nutrient imbalances in the brain5,14.
Cerebral Atrophy: Children with Kwashiorkor often show reduced brain size, also known as cerebral atrophy, due to the lack of protein and essential nutrients needed for brain development. This can result in smaller brain volume, particularly in the cerebral cortex, which is responsible for thinking, memory, and decision-making11,12.Myelin Damage:Protein deficiency affects the formation and maintenance of myelin, the protective coating around nerve fibers. Damage to myelin can slow down brain communication and lead to delays in cognitive and motor function development11,13.
Psychological and Emotional Symptoms Distorted Body Image: People with bulimia often have a warped view of their body shape and size. They may feel overweight even when they are at a normal or low weight 105. Fear of Weight Gain: There is an intense fear of gaining weight, leading individuals to take extreme measures to prevent it 103. Preoccupation with Food, Weight, and Shape: Thoughts about food, weight, and body shape dominate their thoughts, affecting their mood and self-esteem105. Secrecy and Shame: Many try to hide their bingeing and purging behaviors due to shame 107. Mood Swings: Bulimia can be linked to irritability, mood swings, and emotional instability 105. Depression and Anxiety: Individuals with bulimia often experience depression, anxiety, and low self-esteem, which can be present before or develop because of the eating disorder 107. Social Isolation: Feelings of shame and guilt often lead to social withdrawal107. Substance Abuse: Bulimia may co-occur with substance abuse issues, like alcohol or drug use110.
Physical Examination:
- Reviews medical history, eating habits, and purging behaviors103.
Psychological Evaluation:- Assesses thoughts, emotions, and behaviors related to food, body image, anxiety, and depression103.
DSM-5 Criteria:- Self-esteem heavily influenced by body shape and weight103.
Laboratory Tests:Blood Flow
Cold intolerance and blue-tinted extremities: Starvation slows blood flow, causing fingers and ears to appear bluish and making individuals feel cold ⁸⁶.
Changes in reward pathways can make food restriction temporarily relieve anxiety by altering dopamine and serotonin levels. Prolonged malnutrition can lead to brain atrophy, especially in areas managing emotions, reward processing, and self-awareness. Losing weight and controlling food intake might briefly boost self-esteem and lessen anxiety, reinforcing unhealthy behaviors ⁸⁹.
Kwashiorkor is mainly caused by a lack of protein in the diet, even if calorie intake from carbs is sufficient. Without protein, the body can’t build or repair tissues, leading to muscle wasting, edema, and weakened immunity1,2.
Anorexia nervosa often appears to have familial ties, with heritability estimates varying between 28% and 74%. Despite this, the genetic underpinnings of the disorder remain elusive. To date, two large-scale genetic studies, specifically genome-wide association studies (GWAS), have been carried out but they have yet to identify the individual gene associated ⁸², ⁹⁶.
Although marasmus does not directly affect the brain like a neurological disease, chronic malnutrition during critical developmental periods can impair brain growth. Children may show delayed milestones such as sitting, walking, or speaking. Long-term deficits in memory, learning ability, and attention span are commonly observed. The lack of nutrients affects neurotransmitter production and brain plasticity, reducing the capacity for emotional regulation and cognitive flexibility75.
Differences in the Brain:
Structure:
Function:
Orbitofrontal cortex: Involved in reward processing, particularly related to food. This area is larger in people with anorexia, possibly contributing to altered food perceptions¹⁰². Insula: Linked to self-awareness and understanding internal body signals. Increased size in people with anorexia may affect body perception and hunger regulation¹⁰².
Distorted body image involves two brain networks:Parietal Network: This area integrates sensory information and helps accurately perceive one's body size and shape. Dysfunctions here can lead to distorted perceptions, such as seeing body parts as larger or smaller than they are¹⁰². Prefrontal-Insula-Amygdala Network: Manages emotional responses to how one views their body, affecting feelings about appearance¹⁰².
🍼 Inadequate Energy IntakeMarasmus results from a chronic deficiency in calories, particularly from carbohydrates, fats, and proteins. This is almost always due to prolonged undernourishment rather than a specific genetic cause61.
Physical and Biological Factors Contributing to Marasmus:
High Metabolic Demands: Infants require high energy for rapid growth; marasmus occurs when intake doesn’t meet demand54. Compromised Immunity: Undernutrition weakens the immune system, increasing infection risk and nutrient loss55. Gut Malabsorption: Chronic malnutrition damages the intestinal lining (villous atrophy), making nutrient absorption harder56. Micronutrient Deficiencies: Lack of essential vitamins/minerals (e.g. iron, zinc, vitamin A) worsens health outcomes57.
In Kwashiorkor, the body experiences metabolic inflexibility, meaning it cannot effectively switch to using available energy sources when under nutritional stress24. Unlike marasmus (another form of severe malnutrition), children with Kwashiorkor have impaired activation of key survival pathways, including autophagy (the recycling of damaged cell components) and the unfolded protein response in the endoplasmic reticulum25. This leads to cellular stress, dysfunction, and damage, especially in organs like the liver and pancreas26. The suppression of protein synthesis and inadequate stress responses contribute to muscle breakdown, poor wound healing, and immune suppression3,26.
Developmental Risks Contributing to Marasmus:
Premature Weaning: Switching from breast milk too early, especially without nutrient-dense alternatives51. Repeated Infections: Chronic illnesses (e.g. diarrhea, malaria) increase nutritional demands and reduce nutrient absorption52. Low Birth Weight: Infants born small may already have reduced energy reserves53.
Developmental Risks Kwashiorkor Contribute :
Growth Demands: During early childhood, the body needs more protein to support rapid growth and development. Without enough protein, children cannot build muscle, repair tissues, or maintain healthy organs1,10.Physical and Immune Impacts: Protein deficiency leads to stunted growth, muscle wasting, and a weakened immune system. This makes children more prone to infections and delays in physical development1,3,8. Cognitive Development: Without proper nutrition, brain development can be affected. Children may experience delays in speech, movement, and learning abilities, which can have long-term consequences5,11.
Differences in the Brain:
Structure:
Function:
Slowed Cognitive Processing: Due to poor brain nourishment, children may experience slower thinking, learning difficulties, and trouble with attention and memory. These changes are linked to disruptions in neural connections like myelin damage and atrophy in cerebral11,13. Emotional and Behavioral Changes:Kwashiorkor can lead to irritability, apathy, and reduced responsiveness. These symptoms may be related to functional disruptions in areas of the brain that regulate mood and emotional behavior, likely influenced by inflammation and nutrient imbalances in the brain5,14.
Cerebral Atrophy: Children with Kwashiorkor often show reduced brain size, also known as cerebral atrophy, due to the lack of protein and essential nutrients needed for brain development. This can result in smaller brain volume, particularly in the cerebral cortex, which is responsible for thinking, memory, and decision-making11,12.Myelin Damage:Protein deficiency affects the formation and maintenance of myelin, the protective coating around nerve fibers. Damage to myelin can slow down brain communication and lead to delays in cognitive and motor function development11,13.
Kwashiorkor is mainly caused by a lack of protein in the diet, even if calorie intake from carbs is sufficient. Without protein, the body can’t build or repair tissues, leading to muscle wasting, edema, and weakened immunity1,2.
Enviornmental Risks:
Kwashiorkor is strongly influenced by environmental conditions, particularly happens in regions affected by poverty, food insecurity, and limited access to healthcare15. Natural disasters, armed conflict, can severely disrupt food supply chains, leaving communities with diets low in protein16. In many low-income areas, traditional diets rely heavily on starchy foods like maize or cassava, which provide calories but lack essential nutrients17. Lack of nutrition education, poor sanitation, and frequent infections like diarrhea also increase the risk18. These environmental challenges are often made worse by limited government resources and underfunded health systems, making it difficult to prevent or treat malnutrition effectively15,19.